Stent placement for intracranial internal carotid artery dissection presenting with ischemic stroke

Abstract

Objective: Intracranial internal carotid artery (IICA) dissection manifesting as an ischemic stroke is a rare phenomenon, for which the optimal treatment has not yet been established. We report 3 cases, each treated successfully with stent placement. Methods: The data of 3 consecutive patients with IICA dissection treated with stent placement were retrospectively reviewed. Results: The indications for stent placement were impending extensive infarct (n = 2) and recurrent ischemic attack during antithrombotic treatment (n = 1). All dissections were treated with balloon- expandable coronary stents. In all 3 cases, dissection-related vessel abnormalities were resolved after stent placement. No recurrent strokes were observed during the follow-up period (mean, 38.7 months). All cases had excellent or good clinical outcomes at the end of the follow-up. Follow-up angiography showed healing of dissection segments in all patients, without any restenoses. Case 1 was a 28-year-old male patient who presented with progressive hemiparesis on the left side after a sudden headache. A magnetic resonance imaging (MRI) diffusion-weighted image (DWI) showed infarcts in the territory of the right ICA; angiography showed high-grade stenosis and a double lumen in the right supraclinoid ICA. A balloon-expandable coronary stent was placed 4 hours after the onset of symptoms; the stenosis was completely resolved after stenting. Follow-up angiography performed 48 months later showed complete healing of the dissection. The patient had persistent but mild left arm monoparesis. Case 2 was a 29-year- old female patient who presented with hemiparesis on the left side after a seizure. MRI-DWI showed infarcts in the right basal ganglia. Angiography showed a ‘pearl and string’ sign in the right supraclinoid ICA. Anticoagulant therapy was initiated, and her symptoms resolved. The hemiparesis on the left side recurred; however, 4 days after the initial onset, her DWI revealed a new infarct. Stent placement was performed. Angiography obtained 44 months later showed complete healing of the dissection. The patient’s residual symptoms at the conclusion of follow-up were limited to mild monoparesis of the left arm. Case 3 was a 17-year-old male patient who presented with severe right hemiplegia and total aphasia after a sudden headache. MRI revealed a diffusion-perfusion mismatch in the territory of the left ICA, and angiography showed high-grade long segment stenosis in the left supraclinoid ICA. Stent placement was performed 10.5 hours after the onset of symptoms and a complete resolution of the stenosis was achieved. Follow-up angiography obtained 24 months later showed complete healing of the dissection, with residual numbness of the right forearm, the only symptom. Conclusion: Our case series indicates that stent placement may be an effective treatment for intracranial ICA dissection presenting with ischemic stroke. © 2012, The Japanese Society for Neuroendovascular Therapy. All rights reserved.